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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: I� AePATION <br /> (For Non�rans le, Revocable, Suspendable) S <br /> ENVIRONMENTAL PUMP&WELL <br /> ENTAL HEALTH PERMIT I <br /> ,3 _ <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby madeto the San Joaquin Local Health Districtfora permitto construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin Count Ordiinnaance No. 1862 and the 11 9 and regulations of the San Joaquin Local Health District. <br /> Exact Site Address Z22).2 �l /�/l 1 AW City/Town _�Se-A4 .a 1v <br /> P <br /> Owner's Name �l+trhE/1 � �� Phone <br /> t Address / _..s _.._._.._._ QAiy l � �It <br /> Contractor's Name / rr �1.La, IZ / .lr,�G License#,�z�!l� Business Phone <br /> ;5:01-7-7 <br /> Contractor's Address 01 Sc� 11 z i>f ��1 Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL DEEPEN ❑ RECON DITION-15 DESTRUCTION❑ <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank �S� fF Sewer Lines Pit Privy <br /> li r. <br /> Sewage Disposal Field ! �4 Cesspoo I/See page Pit Other <br /> Property Line QPrivate Domestic Well Public Domestic Weil <br /> INTENDED USE " TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> DOMESTIC/PRIVATE i ❑ DRILLED Dia. of Well Casing �I <br /> ❑ DOMESTIC/PUBLIC 1. i� ❑ DRIVEN Gauge of Casing ['ARGA �rla <br /> ❑ IRRIGATION :; ,K-GRAVEL PACK Depth of Grout Seal 570 <br /> ❑ CATHODIC PROTECTION ROTARY Type of Grout <br /> ❑ DISPOSAL OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: �.L�/LrJ Q, <br /> PUMP INSTALLATION: 11 Contractor G <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: 1 ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: j Well Diameter Approximate Depth <br /> II Describe Material and Procedure <br /> I <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws,"and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub -contr11 <br /> acting sig ture certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall.empic pe rso s ubject to workman's compensation laws of California." <br /> 1wilt r a Grou Sp n p r o grousing and a final inspection. � <br /> 11 <br /> Signed X II Title: L- Date: � <br /> (Draw Plot Plan on Reversei e) <br /> li <br /> N FOR D PART ME T USE ONLY <br /> PHASE I <br /> °i <br /> ' Application Accepted By " F^ Date <br /> Additional Comments: <br /> hese II G�1out Inspection P se III Final Inspection <br /> Inspection By Date t�?'/S- e� - Inspection Zeived <br /> Date <br /> Lr :I rbr <br /> Fee Is Due: ❑ ANNUALLY '� ❑ PER UNIT Of PER SITE ❑ EACH ❑ January 1 & By January,31 ❑ Juty 1 &Received By July 31 - <br /> i BILLING REMITTANCE $ REMIT <br /> BASET EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> '3 <br /> FEE !_ <br /> LESS i! <br /> PRORATION <br /> PLUS " I <br /> PENALTY I <br /> OTHER <br /> OTHER �l <br /> i <br /> Received by Date I Receipt No- Permit No- Issuance Date Mailed Delivered - /,t <br /> APPLICANT—RETURN-ALL COPIES TO: ENVIRONMENTAL HEALTH PERMITISERVICES 1691 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95261 (,,��J <br />